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Abstract

Background

This study describes job satisfaction and intention to stay on the job among primary
health-care providers in countries with distinctly different human resources crises,
Afghanistan and Malawi.

Methods

Using a cross-sectional design, we enrolled 87 health-care providers in 32 primary
health-care facilities in Afghanistan and 360 providers in 10 regional hospitals in
Malawi. The study questionnaire was used to assess job satisfaction, intention to
stay on the job and five features of the workplace environment: resources, performance
recognition, financial compensation, training opportunities and safety. Descriptive
analyses, exploratory factor analyses for scale development, bivariate correlation
analyses and bivariate and multiple linear regression analyses were conducted.

Results

The multivariate model for Afghanistan, with demographic, background and work environment
variables, explained 23.9% of variance in job satisfaction (F(9,73) = 5.08; P < 0.01). However, none of the work environment variables were significantly related
to job satisfaction. The multivariate model for intention to stay for Afghanistan
explained 23.6% of variance (F(8,74) = 4.10; P < 0.01). Those with high scores for recognition were more likely to have higher intention
to stay (β = 0.328, P < 0.05). However, being paid an appropriate salary was negatively related to intent
to stay (β = -0.326, P < 0.01). For Malawi, the overall model explained only 9.8% of variance in job satisfaction
(F(8,332) = 4.19; P < 0.01) and 9.1% of variance in intention to stay (F(10,330) = 3.57; P < 0.01).

Conclusions

The construction of concepts of health-care worker satisfaction and intention to stay
on the job are highly dependent on the local context. Although health-care workers
in both Afghanistan and Malawi reported satisfaction with their jobs, the predictors
of satisfaction, and the extent to which those predictors explained variations in
job satisfaction and intention to stay on the job, differed substantially. These findings
demonstrate the need for more detailed comparative human resources for health-care
research, particularly regarding the relative importance of different determinants
of job satisfaction and intention to stay in different contexts and the effectiveness
of interventions designed to improve health-care worker performance and retention.

Keywords:

Afghanistan; Job satisfaction; Malawi; Retention

Background

Efforts to improve national and international health indicators, including the Millennium
Development Goals, are limited by the quantity and quality of human resources for
health (HRH) available to implement lifesaving health-care services [1]. Health-care worker shortages are common globally, but are particularly critical
in areas where health indicators are the poorest. Causes of extreme shortages may
vary greatly from country to country. They include protracted civil war and unrest,
outmigration of trained workers to countries with higher wages and quality of life
and a legacy of insufficient government investment in the health-care sector [2,3]. However, there is widespread recognition that, regardless of the cause, extreme
shortages of qualified health-care workers present significant barriers to health-care
service delivery and that increasing the distribution and retention of health-care
workers is critical to improving health system performance [4,5].

The varied causes, but similar consequences of health-care worker shortages are strikingly
clear in countries as distinct as Afghanistan and Malawi, where Jhpiego, an affiliate
of Johns Hopkins University, has worked with national partners to improve health-care
availability and quality for over 10 years. In Afghanistan, many skilled professionals
fled the country as refugees, and women’s education was halted under Taliban rule,
creating a debilitating shortage of female health-care service providers, who are
particularly critical for providing maternal health-care services [6]. In contrast, the reason for health-care worker shortages in Malawi is not forced
migration, but economically driven outmigration of health-care workers to high-income
countries, with the added service burden of high HIV prevalence rates [7]. Despite such starkly different contexts, the consequences of extreme health-care
worker shortages and demands are similar. Both countries report health-care provider-to-patient
ratios and maternal and child health indicators that are among the worst in the world
[8].

As in many countries where the HRH crisis is most acute, efforts are under way in
both Afghanistan and Malawi to address the crisis by improving the planning, development
and support of the health-care workforce, including improving workplace conditions
to increase health-care worker retention. Since the fall of the Taliban in 2001, the
Ministry of Public Health (MoPH) in Afghanistan has steadily worked to rebuild the
health-care system in collaboration with donors, multilateral organizations and nongovernmental
organizations. From the earliest days of reconstruction, the government has recognized
the key role of human resources in a functioning health-care system, developing a
standardized service delivery package for primary health care and establishing training
programs to address the severe shortage of maternal health-care service providers,
particularly midwives and allied health-care workers [9-11]. Between 2004 and 2010, more than 2,350 women graduated from midwifery education
programs, thus increasing the number of qualified midwives in the country fivefold
from 467 registered with the MoPH in 2002 [12,13]. Shortages of qualified maternal health-care workers remain, however, particularly
in more rural and insecure areas [14].

Malawi has had a national HRH plan to address the shortage of health-care workers
since the late 1990s. One recent initiative supported by the Ministry of Finance,
the UK Department for International Development (DFID) and the Global Fund (implemented
from April 2004 to June 2010) offered financial incentives to health-care workers
in their posts, recruited health-care workers to fill vacancies, expanded preservice
training capacity and strengthened human resources management [15,16]. As a result, from 2004 to 2009, the number of health-care workers increased by 53%
[15]. Even with this increase, retention of health-care staff continues to be a problem
[16]. The health-care worker shortage in Malawi is still at crisis levels, and high HIV
prevalence rates continue to burden the health-care system. The country continues
to have one of the lowest provider-to-patient ratios in the world, with only 3 trained
health-care providers (doctors, nurses and midwives) per 10,000 population [17].

In both Malawi and Afghanistan, like many other countries struggling with extreme
health-care worker shortages, the dearth of trained professionals is further compounded
when health-care workers are drawn to more lucrative jobs in other sectors or are
not willing to be deployed to remote or insecure areas. A growing number of studies
are exploring the factors driving the motivation and retention of health-care workers
in developing countries [2,3,18]. In some contexts, job security, recognition and better living conditions have been
highlighted as key motivators for placement and retention in remote areas. In other
contexts, bundles of interventions that include attention to salary, working conditions
and development opportunities have been successful. Studies in Malawi have indicated
that managers and midlevel health-care providers are motivated by different factors,
but that concerns about salary and career progression are common across all levels
of staff [7,19]. At the time of this writing, no research on health-care worker motivation or retention
in Afghanistan has been conducted.

This study was designed to describe job satisfaction and intention to stay on the
job among primary health-care providers in countries with distinctly different human
resources crises and to examine the extent to which the factors affecting health-care
worker retention in these two countries are captured by existing literature on the
global HRH crisis. Examining the two cases side-by-side provides an opportunity to
reconsider the fundamental characteristics underlying job satisfaction. Its results
are intended to inform policymakers interested in improving health-care workforce
retention in Malawi and Afghanistan, determine the need for further research and serve
as an example for stakeholders in other countries that are interested in understanding
the extent to which strategies to strengthen the health-care workforce must be tailored
to address human resources crises in their own countries.

Methods

Study setting

Afghanistan and Malawi were selected as sites for this study because of the clear
HRH burdens in both settings and because Jhpiego’s long-standing engagement in health-care
sector development in both countries provided an opportunity to incorporate assessments
of health-care provider motivation and retention in evaluations of large-scale health-care
quality assurance and improvement interventions in each country. Given the impact
of the female health-care worker shortage on maternity care in Afghanistan, where
cultural norms prohibit male clinicians from providing services to female patients,
the study was embedded in an evaluation of a US Agency for International Development
(USAID)–funded maternal health-care quality assurance and improvement program at 32
primary health-care facilities in five relatively secure and accessible provinces
of Afghanistan (Baghlan, Herat, Jawzjan, Kabul and Takhar). In Malawi, the provider
motivation and retention assessment was undertaken within the context of infection
prevention–strengthening activities across multiple wards, including (but not exclusively)
maternal health care, in 10 regional hospitals. These two groups of providers are
critical actors within the HRH crisis of each country.

Sample and data collection

In these low-resources facilities, providers who were available and not seeing patients
were recruited. In Afghanistan, facilities included eight district hospitals, 12 comprehensive
health centres and 12 basic health centres. Interviewers recruited a minimum of two
reproductive or maternal health-care service providers per facility. In Malawi, interviewers
recruited a minimum of two providers per department at each hospital. Providers from
seven departments were selected (antenatal care, labour and delivery, family planning,
postnatal care, casualty/medical/surgical, operating theatre and waste management).
Interviews were conducted in local languages by trained data collectors familiar with
the health-care setting. To minimize the potential for social desirability bias, the
interviewer explained the purpose, confidentiality and anonymity of the study to each
provider before seeking consent to begin the interview. Interviews were conducted
face-to-face with clinical health-care providers (medical doctors, nurse midwives,
clinical officers and medical assistants) using a standardized, structured questionnaire.

Ethical considerations

The study received human subjects review and approval from the National Health Sciences
Research Committee in Malawi, the Afghan Public Health Institute in Afghanistan and
the Western Institutional Review Board in the United States. Informed consent was
obtained from all participating health-care providers.

Measures

The study questionnaires (Additional files 1 & 2) were adapted from the Workplace Climate and Job Satisfaction Survey developed under
the USAID-funded Capacity Project and used to assess Kenya’s Emergency Hiring Plan
[20]. The instrument elicited respondents’ background information (control variables),
features of the work environment (independent variables) and job satisfaction and
intent to remain on the job (dependent variables). Background information included
age, gender, marital status, having young children, travel time to work and number
of years at the current health-care facility.

Features of the work environment were assessed using 17 items covering five areas,
namely: resources, performance recognition, financial compensation, training opportunities
and safety. Seven questions were asked about their overall opinions of their jobs:
job satisfaction (i.e., overall job satisfaction, whether respondent would take the
current job if deciding again, whether respondent would recommend a similar job to
a friend, whether respondent would choose his or her current health-care provider
cadre if he or she could choose any type of job) and intention to stay in the current
job as a proxy for actual worker retention (i.e., recently considered switching to
another job, recently considered stopping work, plans to stop work in coming year).
For each of the items related to work environment, job satisfaction and intent to
stay, respondents were asked the following: “Please indicate how much you agree or
disagree with the following statements”. Responses were provided on a five-point Likert-type
scale, from strongly disagree (1) to strongly agree (5). The questionnaire was pretested
before data collection began, and interviewers attended a two-day training program
on how to administer the questionnaire.

The following control variables were included: age, gender, having young children,
time to travel to work and number of years at the same health-care facility. Based
on exploratory data analysis, age was included as a continuous variable for Afghanistan
and a dichotomous variable for Malawi (rating 0 being <40 and rating 1 being 40+).
Number of years at the same facility was categorized into two groups (0 rating being
<2 years and rating 1 being 3+ years). Having young children for whom the health-care
providers had to provide care was a dichotomous variable (rating 0 being yes and rating
1 being no). Time required to travel from home to work was categorized into three
groups (rating 0 being <30 minutes, rating 1 being 30 to 59 minutes and rating 2 being
1 hour to 3 hours).

Scale development

Exploratory factor analyses were conducted on the measures of work environment and
job satisfaction and worker retention using principal component extraction with a
varimax rotation to examine the structure of the responses and determine whether unique
patterns of items could be identified. Internal consistency reliability was assessed
by using Cronbach’s α coefficient. Table 1 presents the psychometrics of aspects of the work environment and job satisfaction,
as well as descriptive statistics (mean ± SD) and the internal reliability of each
item. Most of the constructed variables comprised two- or three-item scales; therefore,
coefficient α values of 0.50 or 0.60 were considered acceptable [20]. For independent variables, the sufficient resources factor encompassed four items (α = 0.63 in Afghanistan; α = 0.59 in Malawi): enough
health-care providers, enough support staff, enough drugs and supplies and adequate
equipment. Two questions were excluded with low item-to-total correlations (expected
to do and overall morale level). The recognition factor encompassed three items (α = 0.69 in Afghanistan; α = 0.55 in Malawi): whether
health-care providers received constructive feedback from a supervisor, whether they
received feedback from a co-worker and whether their contributions were recognized.
The training opportunities factor encompassed two items (α = 0.57 for both Afghanistan and Malawi). However,
the training opportunities factor comprised a different set of variables for each
country. For Afghanistan, it comprised two variables: leave time and training provided.
For Malawi, it comprised training provided and opportunities to receive training.
Being paid an appropriate salary was a single item measured as another aspect of work environment. The safety factor consisted of three items (α = 0.86 in Afghanistan; α = 0.42 in Malawi): feel
safe from physical harm while working, feel safe from physical harm while traveling
to work and policies in place to protect workers from harassment. Higher scores indicate
more positive experiences with the work environment.

Table 1.Psychometric and bivariate comparisons of work environment and job satisfaction measuresa

For dependent variables, principal component factor analysis was conducted on this
measure to determine the underlying factor structure, and the factors were rotated
using the varimax method. The factor solution was composed of seven items grouped
into two factors that accounted for 56.59% of the variance for Afghanistan and 54.36%
for Malawi. In Afghanistan, factor 1, intent to stay (eigenvalue = 2.28), accounted
for 32.55% of the variance with three items, and factor 2, job satisfaction (eigenvalue = 1.68),
accounted for 24.03% of the variance with four items. In Malawi, factor 1, job satisfaction
(eigenvalue = 2.69), accounted for 38.47% of the variance, and factor 2, intent to
stay (eigenvalue = 1.11), accounted for 15.88% of the variance. The four items were
summed together to make a scale of job satisfaction (n = 4, α = 0.55 in Afghanistan; 0.72 in Malawi), representing higher scores with higher
job satisfaction. The three items were summed together to make a scale of intent to
stay (n = 3, α = 0.82 in Afghanistan; α = 0.55 in Malawi), with higher scores representing
higher intention to stay on the job.

Statistical analyses

Four sets of analyses were conducted. First, descriptive analyses were performed to
provide background information on the sample. Second, bivariate comparisons between
the two countries were conducted using t-tests. The third set of analyses examined associations between aspects of the work
environment and the two dependent variables: job satisfaction and intent to stay in
the current job (referred to as intent to stay). Pearson correlation analyses were performed to examine the bivariate relationships
between the main independent variables (i.e., work environment), the control variables
and the two outcomes (job satisfaction and intent to stay). The fourth set of bivariate
and multivariate linear regression analyses examined the relationship between multiple
aspects of the work environment and each of the dependent variables, job satisfaction
and intent to stay. Any variable whose bivariate test had a P-value <0.25 was selected for inclusion in the multivariate model [21]. Lowess plots were used to check the linearity of continuous independent and control
variables. All analyses were performed with Stata version 11.2 software [22].

Results

Sample characteristics

The sample consisted of 87 health-care providers in Afghanistan and 360 health-care
providers in Malawi. Sample characteristics for both countries are presented in Table 2. In Afghanistan, the mean age was 33.4 years (SD 7.62), ranging from 20 to 50 years
old. All providers except one were female. More than two-thirds (69%) were midwives,
16% were nurses, and 13% were physicians. Four-fifths were married, and more than
half had young children. Approximately half travelled to work in less than 30 minutes.
About 43% had worked at the same facility less than two years, and the median was
three years.

Table 2.Sample characteristics of health-care providers in Afghanistan and Malawi

In Malawi, the mean age was 36.7 years (SD ±11.40), ranging from 17 to 75 years old.
Nearly two-thirds of respondents were female. More than one-half (59.2%) were nurses
or midwives, and 11% were medical doctors. About three-fourths were married and had
young children. About three-quarters travelled to work in less than 30 minutes. Approximately
two-fifths (39.3%) reported having worked at the same facility less than two years,
and the median was three years. There were significant differences in gender, marital
status, having young children and travel time between Afghanistan and Malawi.

Job satisfaction and intent to stay

As shown in Table 1, there was no statistically significant difference in job satisfaction between study
participants in Afghanistan and Malawi. However, intent to stay on the job was significantly
higher in Malawi (4.00 on a scale of 1 to 5) than in Afghanistan (2.67). There were
no significant differences in job satisfaction or intent to stay by cadre or by type
of facility (data not shown).

Table 3 presents zero-order correlations between variables in Afghanistan (lower-half matrix)
and Malawi (upper-half matrix). In Afghanistan, job satisfaction was positively correlated
with two aspects of work environment measured at a P-value <0.05 (i.e., Pearson’s r = 0.24 for being paid an appropriate salary; Pearson’s r = 0.22 for training opportunities), whereas intent to stay was negatively correlated
with being paid an appropriate salary (Pearson’s r = -0.22). Recognition was marginally correlated to intent to stay (Pearson’s r = 0.19, P = 0.08). Years on the job was negatively correlated to intent to stay (r = -0.23, P < 0.05). Having young children was positively correlated to job satisfaction (Pearson’s
r = 0.23, P < 0.05), and travel time to work was negatively correlated to job satisfaction (r = -0.42, P < 0.01). All five measures of work environment were significantly correlated to each
other, with the exception that recognition was not correlated with sufficient resources
or safety. Job satisfaction was not correlated with intent to stay.

In both countries, age and years at the same facility were related (Pearson’s r = 0.26, P < 0.05 in Afghanistan; Pearson’s r = 0.47, P < 0.01 in Malawi). Because marital status and having young children were highly correlated
(Pearson’s r = 0.46, P < 0.01 in Afghanistan; Pearson’s r = 0.52, P < 0.01 in Malawi), only the construct having children was included in multivariate
analysis.

Table 4 presents the results of linear regression of job satisfaction and intent to stay
in Afghanistan. In bivariate analysis, time to travel to work, having young children,
cadre, paid an appropriate salary and training opportunities were significantly associated
with job satisfaction (P < 0.05). In multivariate analysis, those who had longer travel time to work (i.e.,
1 to 3 hours) had lower job satisfaction than those whose travel time to work was
less than 30 minutes (β = -0.665). Cadre was associated with job satisfaction: Nurses
or assistant nurses had lower job satisfaction than medical doctors (β = -0.511).
However, none of the work environment variables were related to job satisfaction.
The overall model explained 23.9% of variance in job satisfaction (F(9,73) = 5.08,
P < 0.01).

In bivariate analysis, years on the job and paid an appropriate salary were related
to intention to stay (P < 0.05). Recognition was marginally associated with intent to leave (P = 0.06). In multivariate analysis, those who stayed at the same facility more than
three years had lower intent to stay than those who stayed at the same facility less
than two years (β = -0.613, P < 0.05). Cadre was related to intent to stay: Nurse/nurse assistants were more likely
to have intent to stay than medical doctors (β = 1.098, P < 0.05). Two aspects of work environment, recognition and paid an appropriate salary,
were associated with intent to stay: Those with high scores for recognition were more
likely to have higher intent to stay (β = 0.328, P < 0.05). Interestingly, being paid an appropriate salary was negatively related to
intent to stay (β = -0.326, P < 0.01. The overall model explained 23.6% of variance in intention to stay (F(8,74) = 4.10,
P < 0.01).

Table 5 presents the results of linear regression of job satisfaction and intent to stay
in Malawi. In bivariate analysis, four aspects of the work environment were significantly
associated with job satisfaction: recognition, paid an appropriate salary, training
opportunities and safety. The categorical age variable was also related to job satisfaction.
In multivariate analysis, training opportunities was significantly related to job
satisfaction: Those who had more training opportunities had higher job satisfaction
(β = 0.123, P < 0.05). Safety was marginally associated with job satisfaction (P = 0.067). Those older than 40 years of age reported higher job satisfaction than
those younger than 40 years old. The overall model explained 9.8% of variance in job
satisfaction (F(8,332) = 4.19, P < 0.01).

In bivariate analysis, four aspects of the work environment (i.e., sufficient resources,
recognition, paid an appropriate salary and training opportunities) were associated
with intent to stay. Age and having young children were significantly related to intent
to stay. In multivariate analysis, one aspect of work environment—training opportunities—was
associated with intent to stay: Those with high scores for training opportunities
were more likely to have higher intent to stay (β = 0.101, P < 0.05). Paid an appropriate salary was marginally associated with intent to stay
(P = 0.072). In addition, those older than 40 years of age reported higher intent to
stay than those younger than 40 years old (β = 0.275, P < 0.05). Those without young children reported lower intent to stay than those with
young children (β = -0.373, P < 0.05). The overall model explained 9.1% of variance in intent to stay (F(10,330) = 3.57,
P < 0.01).

Discussion

Simultaneously examining two demographically similar samples of health-care providers
in two very different settings—Malawi and Afghanistan—provides a new lens for understanding
what makes health-care providers satisfied and what makes them want to leave their
jobs. Under this lens, characteristics considered fundamental to job satisfaction,
such as receiving an appropriate salary, can be seen in a new light.

First, although health-care providers in both Afghanistan and Malawi reported that
they were quite satisfied with their jobs, the predictors of satisfaction and the
extent to which those predictors explained variation in job satisfaction differed
substantially between the two study settings. The linear regression results for Afghanistan,
which included demographic, background and work environment variables, explained nearly
one-fourth of the variance in job satisfaction. For Malawi, the same categories of
variables—demographic and background variables and all work environment variables—explained
only one-tenth of the variation in job satisfaction. Variables found to significantly
contribute to the model for Malawi were different from those in the Afghanistan model.
In Malawi, those who reported that they were recognized for their work and those who
had more training opportunities were more satisfied with their jobs, whereas in Afghanistan
only time spent traveling to work was independently significant. It is possible that
facility-associated factors had greater influence on staff satisfaction in Malawi
because the sample was clustered in fewer facilities, with greater likelihood of shared
experiences and influences than in Afghanistan.

Second, though the average respondent in Malawi intended to stay in his or her position,
the average respondent in Afghanistan did not. Predictors of intent to stay and the
extent to which those predictors explained variation in intention also differed substantially
between the two study settings. Background information, demographics and work environment
variables were better predictors of intention to stay for providers in Afghanistan
than for those in Malawi, and the specific indicators were different for the two countries.
In Afghanistan, those who had been on the job less time, those who were nurses, those
who reported being recognized and those who were less likely to report that their
salary was appropriate were more likely to intend to stay in their current positions.
For providers in Malawi, however, those who were older, did not have young children
and received training opportunities were more likely to intend to stay on the job.
In Malawi, younger health-care providers may entertain the idea of possibilities that
they see others taking advantage of, such as emigrating for better opportunities for
their young families, whereas those opportunities are less available to the female
health-care providers in our study living in Afghanistan. The unexpected finding that
providers in Afghanistan who did not feel that their salary was appropriate were more
intent on staying in their jobs calls for further, possibly qualitative, research
to better understand the reasons underlying job retention in this case.

In general, findings from Afghanistan and Malawi are consistent with previous studies
that examined job satisfaction of health-care workers in low-, middle- and high-income
countries. For respondents in both Afghanistan and Malawi, those who received training
opportunities and felt safe from harm at work and traveling to work were more likely
to report that they were paid an appropriate salary. In addition, study results in
Malawi showed that compensation and training opportunities were both strongly correlated
to higher job satisfaction and intent to stay. These results are in line with findings
of previous studies that demonstrate that managers and midlevel health-care providers
are sometimes motivated by different factors, but that concerns about salary and career
progression are common across all levels of staff [3,7,19].

The differences in findings from Afghanistan and Malawi are also consistent with those
reported in the literature. Multicountry studies of health-care worker job satisfaction
have revealed interesting variations between countries, suggesting that macro-level
cultural, economic and political factors, such as labour policies and work culture
and expectations might significantly shape an individual’s attitudes towards his or
her work [24,25]. This study also found variations in the factors related to job satisfaction and
intention to stay across countries. For example, in Malawi, workers who had been at
their facilities longer were more likely to have received greater recognition, specifically
constructive feedback or recognition for doing good work. However, the opposite was
true in Afghanistan; those newer at the facility were more likely to have received
constructive feedback. This could be a function of the how “constructive feedback”
and “recognition” were interpreted by study participants, could simply be an artefact
of how the terms were translated in each country or could be due to other culture-
and context-specific differences. Similarly, in Afghanistan, only one factor, salary,
was related to job satisfaction and intention to stay, whereas in Malawi, four of
the five factors measured were related to job satisfaction and intention to stay.
This difference could be a function of the smaller sample size in Afghanistan or could
be due to other culture- and context-specific differences, such as differences in
expectations of the conditions and benefits a job should provide or levels of inequities
in salary within the health-care sector [26]. For example, on the one hand, it appears that job satisfaction is a more complex
construct in the Malawi setting, is influenced by more factors and, at least in this
sample, is incompletely explained by those health-care workforce indicators typically
considered to be important. On the other hand, the construct of job satisfaction in
Afghanistan seemed to be a simpler concept that was better explained by a small subset
of the factors studied here, particularly “time spent traveling to work”. The fact
that even salary was not a significant predictor of job satisfaction may be a function
of women in Afghanistan being relatively new to the workforce, having been forbidden
from studying and working during the years of Taliban rule. In contrast, those in
Malawi who reported that they were recognized for their work and those who had more
training opportunities were more satisfied with their jobs, which is what is expected
based on previous research. As women become more empowered in Afghanistan to pursue
greater opportunities in the workplace, their expectations of and demands in the workplace
may become more diverse.

These findings demonstrate the need for more detailed comparative HRH research, particularly
on context-specific determinants of job satisfaction and intention to stay, as well
as on the effectiveness of interventions designed to improve health-care worker performance
and retention. Most job satisfaction data are derived from small-scale surveys conducted
with a single category of health-care worker in one country. There have been few job
satisfaction studies conducted to formally compare countries or different health-care
worker cadres, and even fewer have evaluated both [27,28]. Comparative research could help shed light on the essential underpinnings of the
construct of job satisfaction while helping to identify the needs of health-care workers
in specific contexts and informing the design of more effective HRH interventions.
Also, similarly to health-care worker surveys, in our study we did not investigate
whether differences in expressed job satisfaction and intention to stay had any real
impact on health-care worker performance or retention. Further research is needed
to explain some of the associations observed and to investigate their significance
for health-care service delivery. In addition, though there has been increased interest
among researchers and policymakers in identifying and implementing effective solutions
to address HRH shortages in remote and rural areas in recent years, the current evidence
base available to guide policymakers on adoption and adaptation of specific retention
strategies remains quite limited [18,29-31]. Suggested interventions to improve job satisfaction have been extrapolated mostly
from the organizational factors known to be associated with job satisfaction, including
caseload, remuneration, physical working conditions, supervision and leadership. More
attention also needs to be given to developing interventions and strategies that directly
address the factors found to influence provider satisfaction and then to conducting
rigorous intervention research to evaluate the effectiveness of these interventions
on health-care worker performance and retention in various contexts [25].

Interpretation of our study findings is subject to certain limitations. First, the
samples were not designed as nationally representative samples. Second, the samples
were not designed to facilitate direct comparison of a parallel group of health-care
workers in Afghanistan and Malawi; rather, the samples were designed to capture a
group of health-care providers determined to be of particular interest in the context
of the HRH crisis of each country. That said, the two groups were similar in terms
of some demographic characteristics. Participants were health-care professionals who,
on average, were in their mid-30s, and most had been working in the same facility
a fair amount of time (on average more than six years). There were minor, but statistically
significant differences between participants in the two countries in terms of marital
status, having young children and travel time to health-care facilities. One notable
exception is that in Afghanistan almost all participants were women (because of the
maternal health focus and the cultural norms in Afghanistan that restrict male providers
from serving female clients). Third, the studies presented herein were small components
of larger studies and did not collect detailed data on all the myriad individual,
organizational and contextual determinants. Therefore, the available variables explained
only a small proportion of the variation in job satisfaction and intention to leave
in the multiple regression models. Finally, like many other studies of health-care
worker satisfaction and retention, this analysis is based on cross-sectional rather
than longitudinal data and therefore cannot be used to infer causal linkages between
satisfaction and intention to stay or actual turnover.

Conclusions

Health-care worker satisfaction and intention to stay on the job are highly dependent
on the local context. We have shown differences in the levels of job satisfaction
and intention to stay on the job between different groups of health-care workers in
Afghanistan and Malawi, as well as both similarities and differences in the determinants
of health-care worker satisfaction in each country, that are consistent with previous
studies from other low-, middle- and high-income countries. These findings demonstrate
the need for more detailed comparative HRH research, particularly on the relative
importance of different determinants of job satisfaction and intention to stay in
different contexts and on the effectiveness of interventions designed to improve health-care
worker performance and retention.

Abbreviations

DFID: UK Department for International Development; HRH: Human Resources for Health,
Global Health Workforce Alliance/World Health Organization; MoPH: Ministry of Public
Health of Afghanistan; USAID: US Agency for International Development.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

LF led the interpretation of results and writing and revision of the manuscript. YMK
designed the study, served as the Principal Investigator and contributed to the writing
and revision of the manuscript. HSJ conducted the analysis and contributed to the
writing and revision of the manuscript. HT contributed to the interpretation of results
and the writing and revision of the manuscript. JWN conducted the literature review
and contributed to the first draft of the manuscript. PZ participated in the design
and implementation of the study in Afghanistan and contributed to the interpretation
of study findings and revision of the manuscript. AR participated in the design and
implementation of the study in Malawi and contributed to the interpretation of study
findings and writing of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors acknowledge the contributions of Nasrat Ansari, Eva Bazant, Kyungsuk Jung,
Tambudzai Rashidi, Barbara Rawlins, Reena Sethi and Khalid Yari to the studies of
job satisfaction and retention of health-care providers in Afghanistan and Malawi.
This research would not have been possible without the support of the Ministry of
Public Health in Afghanistan and the Ministry of Health in Malawi. Funding for the
research in Afghanistan was provided by the US Agency for International Development.

References

Bailey RJ, Dal Poz M: Building the public health workforce to achieve health-related development goals:
moving forward in collaboration.